Transcript Managing Childhood Asthma in the Child Care and Preschool

Asthma Management Update
Lisa Musso, ARNP, MN, CPNP
Division of Pediatric Pulmonary Medicine
Children’s Hospital and Regional Medical
Center
Asthma Management Update
Objectives:
Upon completion of this session, participants
will be able to:
Describe three changes that asthma causes
in the airway
Identify two types of medicine used to treat
asthma
List three typical asthma triggers and ways of
minimizing their effect
Asthma Management Update
Overview:
Airway Changes in Asthma
How is Asthma Managed - Medications,
Trigger Management
Asthma Management Plan - Working with
the Parent and Health Care Provider
Triggers
Trigger Management
What is Asthma?
Definition of Asthma:
Lung disease characterized by;
reversible airway obstruction
 airway inflammation
 increased airway responsiveness

Pathophysiology
Airway Changes:
Physiologic response
inflammation
 bronchoconstriction
 hypersecretion of mucus
 All lead to airway plugging, hyperinflation
and atelectasis.

Airways in Untreated Asthma
Airways After Administration of a Bronchodilator
Airways After Addition of an Inhaled Corticosteroid
Asthma Severity
Mild Intermittent
days with symptoms: < 2/week
 nights with symptoms: < 2/month
 FEV1 or PEF: > 80%

Asthma Severity
Mild Persistent
days with symptoms: >2/week
 nights with symptoms: 3 - 4/month
 FEV1 or PEF: > 80%

Asthma Severity
Quick review of asthma severity
Moderate persistent
days with symptoms: daily
 nights with symptoms: > 5/month
 FEV1 or PEF . 60% to <80%

Asthma Severity
Quick review of asthma severity
Severe persistent
days with symptoms: continual
 nights with symptoms: frequent
 FEV1 or PEF: < 60%

Comparison of Asthma Severity Levels
Severity
Daytime
Symptoms
Nighttime
Symptoms
Lung
Functions
Mild
Intermittent
Less than or
equal to 2 times
per week
Less than 2
times per month
FEV1 or PEF of
greater than or equal
to 80% Variability <
20%
Mild Persistent
3-6 times per
week
3-4 times per
month
FEV1 or PEF of
greater than or equal
to 80% Variability of
20-30%
Moderate
Persistent
Daily symptoms
Greater than or
equal to 5 times
per month
FEV1 or PEF 60-80%
Variability > 30%
Severe
Persistent
Continual
symptoms
Greater than 5
times per month
FEV1 or PEF less
than 60%
Variability > 30%
Triggers
Viral infections
Cigarette smoke
Pets
Exercise
Strong emotion
Strong odors
Heart burn
GE Reflux
Seasonal allergies
Dust mites
Mold
Cold weather
Change in weather
Air pollution
Wood burning
stoves
Aspirin Sensitivity
Infections
Upper Respiratory infections
Viral or bacterial
“colds”
ear aches
sinus
“flu”
Smoke
Active smoking
Passive smoking
Inside/outside home
Inside/outside car
Animals
Furry, hairy

Shedding
Cats
 Dogs
 Birds
 Rabbits, hamsters, guinea pigs,rats

To Run and Play
Exercise
How much is too much
 Recess
 Gym
 Team Sports

To laugh or cry
Laughing
Crying
Stress
Anger
Anxious
Scared
Things that Smell
Perfume/cologne
Incense
Wood burning stoves
Paint
Cleaning products
Hair products
Foods
Allergens
dust mites
animal dander
molds, mildew, fungi
pollens—grass, trees, weeds
cockroaches
Cold or Warm Air – Weather
Changes
Cold air versus warm air
To exercise or not
Weather changes
Prevention Strategies
Infections
Prevention

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
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Good hand washing
Use of tissues
Cleaning of school areas
Cleaning of toys
Sharing of school supplies, equipment, toys
Staying at home
Completion of course of medication if given
Tobacco Smoke
Controlling environmental tobacco smoke:
smoke-free child care environment
smoke-free vehicle
quit smoking
smoke outside wearing “smoking jacket”
Animal Dander
Controlling animal dander:
keep cats, dogs, and other furry animals
out of children’s area
replace w/non furred or feathered
animals
Molds
Controlling molds, mildews and fungi:
locate and remove mold growth
check walls, floors, window molding,
ceiling, under carpet
don’t lay carpet on cement
prevent growth w/ good ventilation
Roaches
Controlling cockroaches:
restrict where food is eaten
clean up after food preparation
do not leave out pet food overnight
cover trash bins
don’t store paper products/ bottles at
floor level
repair cracks, holes in foundation,
plumbing, walls
fix leaky faucets
Pollens
Controlling pollen exposure:
minimize outdoor activity on high pollen
days
close windows and doors on high pollen
days
run air conditioning
allergy medicine as directed by
parent/provider
Allergy Control
Controlling dust mites:
cover mattresses and pillows
minimize stuffed animals
remove upholstered furniture
vacuum frequently w/children absent
maintain humidity @ about 40%
filters over heating ducts
washable rugs instead of carpets
Air Pollution
Controlling exposure to air
pollution/ozone:
Minimize outside activity on high
pollution
days
avoid ozone-generating air cleaners
Odors---the good and the bad
Controlling exposure to
fumes/sprays/strong odors:
avoid aerosol sprays
avoid strong “clean” smelling sprays
avoid perfumes, after shave, candles,
potpourri, incense
clean with weak bleach solution and let
air dry (see handout)
Exercise
Dealing with exercise-induced asthma:
pre-treat as directed by parent/ provider
Cover mouth and nose
warm up before strenuous exercise
rest periods
minimize outdoor activity if high level of
triggers are present
Triggers
Drop in peak flow
cough
wheeze
cold symptoms
chest tightness
difficulty breathing
Fast breathing
shortness of breath
restlessness
poor appetite
headache
dark circles
Medications
Controller
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Cromolyn sodium
Nedocromil sodium
Inhaled Corticosteroids
Leukotriene modifiers
Long acting Beta 2
Sustained released
theophylline
Nebulized steroids
Rescue


Short acting Beta 2
Oral steroids (short
burst)
Gadgets and Gizmos
Nebulizers
metered dose inhaler (MDI)
spacer /spacer with mask
diskhaler
Aerolizers
Turbohaler
dry powder inhaler
tablets
liquids
Peak Flow Meters
What do they really tell you?
If asthma is worsening
 If asthma is better or worse
 If medications is helping
 Are you really having an asthma attack

Peak Flow Meters
Who should use one?
Moderate to severe asthmatics
 Poor perceivers of severity of symptoms
 Newly diagnosed
 History of severe exacerbations
 Exercised Induced Asthmatics

Peak Flow Zones
Zones
Signs and Symptoms
Plan
Green
80% of predicted
No asthma symptoms
No night time cough
Normal activities
No need for rescue
medications
Having some asthma
symptoms
Drop in peak flow
Take controller
medications daily
Have rescue
medications handy
Yellow
50 - 80% of
predicted
Red
Increased asthma symptoms
Less than 50% of Drop in peak flow
predicted
Poor or no response to rescue
medications
Take controller
medications
Use rescue
medications
Monitor for
Take
controller
improvement
medications daily
Have rescue
medications handy
Asthma Management Plans
Definition:

an written educational tool or plan which
describes daily management and how to
handle asthma episodes/excerbations
ASTHMA MANAGEMENT PLANName__________________________________________Drug Allergies__________________________
Weight________
Green Zone: Go
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No symptoms of an asthma episode (no
coughing, no wheezing, no shortness of
breath, no nighttime awakenings)
Able to do usual activities, run, play,
attend school. Usual medications
control asthma
Peak Flow 80% of personal best
PFM________to________
Yellow Zone:
Caution
Increased asthma symptoms,
Plan A: Take these preventative medicines all the time:
Controller/Preventative Medicine
How delivered
How much
How often
 coughing
 wheezing
 shortness of breath
 tightness in chest
 other______________
Known
Asthma
Triggers
15-20 minutes before sports/exercising take:
Plan B: Continue Plan A and add these quick relief medicines:
Short-Acting 2 Medicine
How delivered
How much
How often
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increased coughing, wheezing, work of
breathing, shortness of breath,
retractions, awakening at night
Usual activities somewhat limited,
unable to run, play, attend school as
can normally
Increased need for asthma medication
Peak Flow 50-80% of personal best
PFM__________to__________
Red Zone:
Very
short of breath, coughing and
DANGER
wheezing that won’t stop
Usual activities severely limited, can’t walk,
run, play, sleep or need to sleep upright
Asthma symptoms have not gone away or
return quickly (less than 4 hours) despite
using asthma medications
Can’t talk in complete sentences, ribs show
with each breath
Peak Flow less than 50% of personal best
PFM less than ______________
Known
Asthma
Symptoms
 respiratory infection
 animals
(specify)_______
 foods (specify)
________
 cigarette smoke
 pollens/mold
If you feel better after taking this medication: Go back to your Green Zone medications and recheck
every 4 hours for continued improvement or worsening of asthma symptoms. If you DO NOT feel
better in 20 to 60 minutes or if you need Albuterol every 4 hours then Follow the RED ZONE Plan.
Plan C: This is a Danger Zone! Take these medicines immediately!
Short-Acting 2 Medicine
How delivered
How much
How often
 temperature changes
 strong odors or fumes
 exercise
 wood smoke
 dust/chalk dust
 other
________________
Asthma
Management
Plan
Oral steroid dose
Next, call your own physician for further instructions.
BUT, see the doctor RIGHT AWAY or go to the hospital if ANY of these things are happening:
• Lips or fingernails are blue or gray, or • You are struggling to breathe, or
• You do not feel any better 20 to 30 minutes after taking the extra medicine.
FOR SCHOOL AND CHILD CARE MEDICATION PERMISSION: This patient has been
instructed in the proper way to take his/her medications. He/she is capable of self-administering
PARENT
medications: ___Yes ___No
SIGNATURE ________________________________________________ He/she can reliably report asthma symptoms: ___Yes ___No
Health Care Provider’s
Signature___________________________________________Date_________________
Date signed_________________________
ASTHMA
DISEASE
MANAGEMENT
PROGRAM
What does this mean in real
life?
No coughing
No difficulty
breathing
No waking at night
Normal activities
No acute episodes
that require PCP
visit, ER or
hospitalization
No absences from
school or work
Normal ( or near
normal) lung
function
Summary
Asthma is a chronic disease
It is controllable, some exacerbations
sometimes can be prevented
Different medications treat the different
phases of asthma
Asthma Management Plans really do
help
School Nurses do a great job!
Questions
References
Helpful Web Resources
http://www.ginasthma.com
 http://www.guidelines.gov
 http://nhlbi.nih.gov
 http://lungusa.org
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